CONTACT
INFO |
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Address: |
, |
Phone: |
1-855-696-3446 |
Provider Phone: |
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Fax: |
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Website: |
Program Website |
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ELIGIBILITY
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Eligibility
Info: |
Eligibility is determined on a case-by-case basis.
Patient with Medicare Part D may be eligible if medication is not covered.
This program provides financial and reimbursement support. Co-Pay assistance is available to insured patients. |
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Couple |
|
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
No |
US citizenship/residency specified:
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Yes |
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APPLICATION |
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Attachments
Required: |
Financial
|
Physician
License #
Required: |
Not Required
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Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
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Eligibility
determination
letter sent: |
Both Provider and Patient
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MEDICATION |
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Receives: |
Medication
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Shipped To: |
Not Published
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Quantity in
Shipment: |
Not Published
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Delivery Time: |
Not Published
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Re-application
Policy: |
Not Published |
Refill Policy: |
Not Published
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Other Information: |
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